Provider Demographics
NPI:1760601488
Name:EVERETT OPTOMETRY CLINIC, PS
Entity Type:Organization
Organization Name:EVERETT OPTOMETRY CLINIC, PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMY
Authorized Official - Middle Name:K
Authorized Official - Last Name:ROSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-252-3937
Mailing Address - Street 1:PO BOX 986
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98206-0986
Mailing Address - Country:US
Mailing Address - Phone:425-252-3937
Mailing Address - Fax:425-259-3895
Practice Address - Street 1:3700 COLBY AVE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-4911
Practice Address - Country:US
Practice Address - Phone:425-252-3937
Practice Address - Fax:425-259-3895
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2008-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA0869152W00000X
WA3029152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2208908Medicaid
WA2208916Medicaid
WA2208908Medicaid
WAG001201586Medicare PIN
WAG001200125Medicare PIN
WA4113520001Medicare NSC
WAU42310Medicare UPIN